cytotec question

This is why I hate cytotec.

I'd do your standards for intrauterine resuscitation - turn onto left side, oxygen (unless FHR is fabulously reactive), IVF bolus if no contra-indications.

If no accels and decreased variability, I'd call the doc again and specifically request tocolytics.

If late decels, our facility has a policy in place where we can give one dose of brethine for hyperstim + fetal distress and then call.

The babys EFM strip looks good and is reactive but only mom is contracting every minute, so is it necessary to try to stop the contractions? thanks for the reply.

Mom may be contracting every minute but how long are they lasting and are they mild to palpation? We've had many mothers come in for NST or other reason, put them on the monitor and they are contracting every 1-2 minutes and don't even know it. It could just be uterine irritability. As long as the tracing is reactive without decels, I'd probably not worry too much about them. Just don't put another Cytotec in!

I suppose it depends on the strength of the contractions but if they are strong enough for mom to sit up and take notice, then if the contractions don't slow down and/or ease up, something will eventually give. Whether that be the baby and/or mom, something will wear out with that type of continuous contraction pattern.

You mention the frequency of the contractions, but don't mention the duration or strength. Sometimes those high frequency/low amplitude contractions can be knocked out with IV fluids. Many patients get a "hyperstim" reaction to a prostiglandin/cytotec. Was mom feeling those contractions? If it were my patient, I would hang fluids and see what happens. If the hyperstim continues I would be calling the doc and informing him, and documenting that I did so, along with my interventions. The old school of thought was....if mom wasn't feeling the contractions..neither was the baby. We know that not to be true now. There are studies now (when fetal pulse ox was being used) that over a period of time (I think it was 8 mins or so) of a hyperstim pattern (more than 5 contractions in 10 mins) that fetal pulse ox dropped as a result of decreased placental perfusion because of lack of rest in between contractions. A good thing to remember when you are Pit-ing the crap out of someone.

Bolusing with fluids can definitely help, yes. So can repositioning on left side and giving oxygen by nonrebreather mask at 10 liters. You need to know your policies and procedures like the back of your hand, particularly pertaining to induction/augumentation of labor. If you violate them, despite what the physician "wants" or not, you will find yourself in trouble, obviously. Don't be afraid to ask for help from a more experienced colleague in cases like this---this person ideally will be very experienced in fetal heart monitoring and labor and delivery nursing---- and will be able to guide you as to whether you are dealing with hyperstimulation that needs treatment, or not.

If dangerous hyperstimulation is indeed the case, and the physician is unwilling to come in and evaluate your patient or take action, you may have to take it up the chain of command . Particularly if the fetus or mother are having any adverse reactions, even if there is no hyperstimulation----you have no choice but to act promptly.

I wish you well.

If the baby looks good, I'd hold off on the O2. It's uncomfortable, upsets and frightens the patient, and once it's started, it often remains on the rest of the labor. Of course, if the baby does not look wonderful--start it.

Definitely reposition the patient. If she's on her back, turning her to one side or the other, or even sitting her up often spaces the contractions out. So may some fluid. Or maybe she just needed to empty her bladder.

As others have said, it's important to note the the response of the fetus and the quality and length of the contractions as well as the frequency.

The reason I recommend oxygen, is the OP brought up the fact she felt there was hyperstimulation and wanted to do something about it. Not being there, I don't know if there was a real problem or not. But if there was some hyperstimulation, fluid boluses and (temporary) application of oxygen can indeed help and often be done quickly without further intervention necessary. If you are calm and explain the reason for these interventions, most patients remain calm and cooperative also. I agree, oxygen masks are uncomfortable (and they smell awful, I remember from wearing one!)---- and they should be used only as necessary. When the situation is resolved, the mask definately needs to come off! We are often remiss in taking off O's when the situation no longer calls for them.

You bring up some very good points, Nora.

You're right, I wouldn't put oxygen on if the FHR was reactive. The mask is a tangible reminder to mom that all is not well right now, and can increase her stress level, which certainly doesn't help!

Thank you everyone for your response, all the answers really helped. I work at a small community hospital and usually there is only two or three nurses a shift but on that night the other two nurses called in sick and I was left with one registry nurse....very scary night!!!

You didn't mention how long the Cytotec was in before the hyperstim began. Sometimes when first inserting Cytotec or Cervidil I have noticed and increase in contraction frequency which levels out after about an hour. If it has been longer than an hour since the Cytotec insertion and the ctx. are more than 5 in 10 minutes, I would do what everyone above suggests. If not, give her an hour and see what happens. Some of the new literature I have read on oxygen suggests that putting on an O2 mask should only be done at ten minute intervals - ten on then ten off - as it is no longer effective after ten minutes. IVF's have definitely showed to space out ctx. in early and preterm labor so maybe it would help. If not, as suggested above, go up the chain of command until something is done.

You didn't mention how long the Cytotec was in before the hyperstim began. Sometimes when first inserting Cytotec or Cervidil I have noticed and increase in contraction frequency which levels out after about an hour. If it has been longer than an hour since the Cytotec insertion and the ctx. are more than 5 in 10 minutes, I would do what everyone above suggests. If not, give her an hour and see what happens. Some of the new literature I have read on oxygen suggests that putting on an O2 mask should only be done at ten minute intervals - ten on then ten off - as it is no longer effective after ten minutes. IVF's have definitely showed to space out ctx. in early and preterm labor so maybe it would help. If not, as suggested above, go up the chain of command until something is done.

How does IVF space out ctx's (in general)?. What is the physiology behind it?